Nursing textbooks medical-surgical practice questions, set 16
Nursing textbooks · medical-surgical
Nursing textbooks medical-surgical practice questionsset 16
You practice adult health stems across systems, then name the action that changes the outcome. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the Nursing textbooks exam guide or more Nursing textbooks practice questions.
Five medical-surgical questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
A patient diagnosed with schizophrenia tells the nurse, 'The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say.' Which response by the nurse would be most therapeutic?
A. Let's talk about something other than the CIA.
B. It sounds like you're concerned about your privacy.
C. The CIA is prohibited from operating in health care facilities.
D. You have lost touch with reality, which is a symptom of your illness.
Show answer and rationale
Correct answer: B — It sounds like you're concerned about your privacy.
It is important not to challenge the patient's beliefs, even if they are unrealistic. Challenging undermines the patient's trust in the nurse. The nurse should try to understand the underlying feelings or thoughts the patient's message conveys. The correct response uses the therapeutic technique of reflection. The other comments are nontherapeutic. Asking to talk about something other than the concern at hand is changing the subject. Saying that the CIA is prohibited from operating in health care facilities gives false reassurance. Stating that the patient has lost touch with reality is truthful but uncompassionate.
Question 2
A client with Parkinson's disease is undergoing treatment in a health care facility. Which of the following nursing interventions should the nurse perform as part of the client's ongoing assessment?
A. Assess the client for ability to perform the daily activities.
B. Observe the current mental condition of the client.
C. Observe the client for various neuromuscular signs.
D. Prepare a baseline for future evaluations of the client's drug therapy.
Show answer and rationale
Correct answer: C — Observe the client for various neuromuscular signs.
The nurse should evaluate the client's response to drug therapy by observing the client for various neuromuscular signs to compare these observations with the data obtained during the initial physical assessment. The nurse should assess the clients ability to perform daily activities and observe the client's current mental condition before the drug is administered to the client as part of the preadministration assessment. During the preadministration assessment, before starting the drug therapy, the nurse also performs a physical assessment of the client to provide a baseline for future evaluations of drug therapy.
Question 3
A student nurse asks the nursing instructor, 'What will my role as a nurse encompass after I graduate?' What is the best response by the nursing instructor?
A. You will take care of clients who are ill in a hospital or long-term care facility.'
B. You will care for individuals and families and play a role in health education, illness prevention, and promotion.'
C. You will care for a variety of clients of all ages when they are ill.'
D. It will all depend on where you want to work when you graduate. Nurses do different things in healthcare.'
Show answer and rationale
Correct answer: B — You will care for individuals and families and play a role in health education, illness prevention, and promotion.'
Nursing is concerned with caring for individuals, families, or groups. Nurses not only care for clients when they are ill but also play a significant role in health education, illness prevention, and promotion. Nurses attend to client needs related to: hygiene; activity; diet; the environment; medical treatment; and physical, emotional, and spiritual comfort. Therefore, nurses care for clients in a variety of settings, not just hospitals or long-term care facilities. Though nurses may choose to specialize in a certain area of healthcare, all these areas involve health education and promotion and illness prevention.
Question 4
The nurse is instructing a couple in the early stages of infertility testing who has just found that the male has a slightly low sperm count. Which easy change can a nurse suggest to a male client?
A. Avoid riding on motorcycles
B. Wear loose fitting underwear instead of tight ones.
C. Take a general multivitamin.
D. Increase sexual intercourse to every day.
Show answer and rationale
Correct answer: B — Wear loose fitting underwear instead of tight ones.
Wearing loose fitting underwear allows the scrotum to pull the testes closer to the body to maintain proper temperature for sperm production or allow the testes to be farther from the body. Because the testes cannot produce viable sperm when temperatures are at or above body temperature, their location within the scrotal sac ensures optimal conditions. There is no evidence that the client cannot ride motorcycles. Taking a general multivitamin is encouraged for overall health. Daily sexual intercourse is not encouraged because it is most important to have sufficient sperm present during a female's ovulation period.
Question 5
The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate?
A. Using the Romberg test
B. Observing the reaction of pupils to light
C. Observing the client's response to painful stimuli
D. Monitoring the client's sensitivity to temperature, touch, and pain
Show answer and rationale
Correct answer: C — Observing the client's response to painful stimuli
Assessment of motor function includes muscle movement, size, tone, strength, and coordination. The nurse evaluates motor response in the comatose or unconscious client by administering a painful stimulus to determine the client's response. An appropriate response is for the client to reach toward or withdraw from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Observing the reaction of the client's pupils to light is an oculomotor cranial nerve assessment. Monitoring sensitivity to temperature, touch, and pain assesses the sensory function of the client and not motor response.
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Question 6
The client is receiving chemotherapy for a diagnosis of lymphosarcoma. The client experiences nausea. What measures should the nurse suggest to help the client reduce the feeling of nausea?
A. Administer immunosuppressive drugs.
B. Apply ice to the skin for brief periods.
C. Offer clear liquids such as carbonated beverages, water, and ice pops.
D. Advise bed rest as much as possible.
Correct answer:
To help reduce the feeling of nausea in a client who underwent chemotherapy, the nurse should offer clear liquids such as carbonated beverages, water, ice pops, and gelatin until the nausea subsides. Immunosuppressive drugs are known to cause non-Hodgkin's lymphoma when administered to prevent a transplant rejection. These drugs do not help in reducing the feeling of nausea. The nurse may need to apply ice to the skin to prevent it from itching and thereby promote the skin integrity. Bed rest, analgesic and antipyretic therapy, and increased fluid intake are recommended to clients with infectious mononucleosis.
A client with lymphadenitis has developed persistent swelling of the affected area. What would be important information for the nurse to teach this client?
A. How to apply an elastic sleeve or stocking
B. How to apply ice to the affected area
C. How to do exercises to increase blood flow in the area
D. How to dependently do activities of daily living
Correct answer:
The nurse inspects the area two to three times daily and notes the client's response to antibiotic therapy. He or she gives assistance if the discomfort interferes with activities of daily living. Elevation reduces the swelling. Warmth promotes comfort and enhances circulation. The nurse notifies the physician if the affected area appears to enlarge, additional lymph nodes become involved, or body temperature remains elevated. In severe cases with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. Ice does not reduce the swelling. Exercise does not reduce the swelling.
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client reports being allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?
A. Apply an allergy bracelet and flag the chart.
B. Tape an EpiPen to the head of the bed.
C. Inform the client not to take any medications with those substances in them.
D. Call the physician.
Correct answer:
The nurse asks each client about the existence of any allergies. If any are reported, the nurse flags the medical record and applies a wristband with the appropriate information. Throughout the client's care, the nurse observes for signs of an allergic reaction, especially when administering medication, applying substances such as tape or adhesive patches to the skin. Medication should never be left in the client's room. The responsibility for medications with the identified allergens lies with the healthcare personnel in the acute care facility. The physician does not need to be called if the chart is flagged.
The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurses plan of care should include which of the following interventions?
A. Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good
B. Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months
C. Promoting communication with the patient and family along with addressing end-of-life issues
D. Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea
Correct answer:
Promoting communication with the patient and family is a critical role of the nurse with a patient in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the patients wishes. Many cases of MODS result in death and the life expectancy of patients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the patient.
An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins?
A. Sit with crossed legs for a few minutes each hour to promote relaxation.
B. Walk for several minutes every hour to promote circulation.
C. Elevate the legs when tired.
D. Wear snug-fitting ankle socks to decrease edema.
Correct answer:
A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation. Sitting with crossed legs may promote relaxation, but it is contraindicated for patients with, or at risk for, varicose veins. Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves in the veins. Wearing tight ankle socks is contraindicated for patients with, or at risk for, varicose veins; socks that are below the muscles of the calf do not promote venous return, the socks simply capture the blood and promote venous stasis.
Which nursing diagnosis is likely to apply to the plan of care for a homeless individual diagnosed with severe and persistent mental illness?
A. Insomnia
B. Substance abuse
C. Chronic low self-esteem
D. Impaired environmental interpretation syndrome
Correct answer:
Many individuals with severe mental illness do not live with their families and are homeless. Life on the street or in a shelter has a negative influence on the individual's self-esteem, making this nursing diagnosis one that should be considered. Insomnia may be noted in some patients but is not a universal problem. While substance abuse may be a comorbid problem, it is not an approved North American Nursing Diagnosis Association International (NANDA-I) diagnosis. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not observed in a majority of the homeless population.
The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?
A. Progressive tissue damage without any verifiable etiology
B. Absence of a triggering event
C. Profound fatigue with no identifiable cause
D. Affects only older adults and infants less than 3 months
Correct answer:
Diseases are considered autoimmune disorders and are characterized by unrelenting, progressive tissue damage without any verifiable etiology. In many autoimmune disorders, there tends to be a triggering event, such as an infection, trauma, or introduction of a drug that integrates itself into the membranes of the host's cells. Although older adults face a greater risk of developing autoimmune disorders, persons belonging to any age-group can be affected. Chronic fatigue syndrome is primarily characterized by profound fatigue with no identifiable cause, and this is not a characteristic of autoimmune disorders.
A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this client's teaching prior to beginning rehabilitation activities?
A. Use analgesic before and after activity, even if you are not experiencing pain.
B. Let me know if you start to experience shortness of breath, chest pain, or fatigue.
C. Use physical therapy before and after activity.
D. If you experience knee pain, ask the physical therapist to reschedule your therapy.
Correct answer:
Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. The nurse must instruct the client to report symptoms such as shortness of breath, chest pain, or fatigue, which indicate that the heart is not receiving adequate oxygen during activity. Using analgesics prophylactically is not necessary unless prescribed. Physical therapy is a structured program, not something used before and after activity. Rescheduling therapy due to knee pain may delay recovery, and pain should be managed appropriately instead.
A nurse working in the pulmonary clinic is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend?
A. Avoid exercise.
B. Take steps to manage or reduce anxiety.
C. Eat meals 1 to 2 hours prior to breathing treatments.
D. Eat a high-protein/high-calorie diet.
E. Maintain a high-Fowler position when possible.
Correct answer:
When caring for patients with COPD, it is important to help create an environment that is likely to reduce anxiety, which increases oxygen demand. A high-protein/high-calorie diet is recommended to meet increased energy needs due to the work of breathing. People with dyspnea and orthopnea are most comfortable in a high-Fowler (upright) position because accessory muscles can easily be used to facilitate respiration and lung expansion. Meals should be eaten 1 to 2 hours after breathing treatments; exercise and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended, rather than 2 to 3 pints.
The nurse is leading a cardiac rehabilitation support group. How can the nurse best demonstrate meeting the client's needs holistically?
A. Lead an exercise, show a video about healthy lifestyle changes, and invite a spiritual leader to talk with the group.
B. Have the clients share various healthy low-cholesterol recipes and participate in a cooking class.
C. Have the clients discuss ways to relieve stress and practice stress reduction.
D. Demonstrate low-impact aerobic exercise to the group and bring in a lecturer on Tai Chi.
Correct answer:
Nurses practice from the perspective of holism, which is viewing a person's health as a state balance between body, mind, and spirit. Leading an exercise, showing a video about healthy lifestyle changes, and inviting a spiritual leader to talk with the support group are all ways the nurse can meet the clients' needs holistically. By combining these activities, the nurse addresses the needs of the body, mind, and spirit. Cooking classes, having clients discuss stress reduction, and demonstrating exercise techniques are each only addressing one type of need, and therefore are not on their own holistic methods.
About these Nursing textbooks medical-surgical questions
Nursing textbooks medical-surgical practice questions, set 16 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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